Part 1 in our Title 25 series. Read Part 2 here.
If you want to get the full picture of how the Title 25 process works in Wyoming you need to talk to Chel Bleckler. That’s because she spent over a decade working in an E.R. in Cody, where a big part of her job was working with Title 25 patients.
“Usually they came in with the police,” she said sitting on the couch of a counseling office in Cody. “And you could always tell the ones because they were crying or they were mad or they were handcuffed.”
Bleckler also has some personal expertise: she’s been detained and treated against her will for mental health issues herself. On the day she was held and taken by ambulance to Wyoming Behavioral Institute in Casper she had already sent four other Title 25 patients to that hospital. ”So I get down there and they go ‘hey, aren’t you the lady that got everything ready for me?’ And I’m like yeah, I just need a vacation.”
But before we can understand Bleckler’s experience we need to understand how the Title 25 process works. It begins when law enforcement deems someone to be a “danger to himself or others,” usually after a 911 call from a concerned family member or friend. The police take them to a hospital to get evaluated by a doctor. If the doctor thinks they are having mental health issues--not just a medical problem or drug use--they will bring in a Master’s level therapist. “It’s a form,” said Bleckler. “How’s their appearance: neat, tidy, dishevelled? How is their speech? Based on their interview with that person they make their decision to title.”
If someone is "Titled" they can be initially held for up to 72 business hours. Before the end of that three days the patient must see a judge, who has the power to decide whether to extend the mandatory psychiatric care, or release them. The county where the patient is located is responsible for paying for those first 72 hours, but the Wyoming state government is responsible for paying for any treatment afterwards.
Chel Bleckler knew all this abstractly, but it became personal a few years ago. Bleckler has bipolar disorder, and suffers periodic psychotic episodes brought on by thyroid issues. During one of these episodes she checked herself into the hospital.
“I couldn’t quit crying and I couldn’t sleep,” she said. “And I had only had an hours sleep for like three weeks. And I thought they were going to get a hold of my psychiatrist, maybe admit me, and give me a bowl of elephant tranquilizers. I thought I could sleep for a day or two and I would be better.”
But the doctors who knew her conditions were not working that evening, and Bleckler was "Titled". In Cody that means a four and a half hour ambulance ride to the Wyoming Behavioral Institute in Casper. Bleckler arrived on a Friday. Monday was a holiday, so she didn’t get to see a psychologist until Tuesday morning. She said he recognized that she was having a thyroid episode almost immediately--Bleckler was released within an hour.
But that was not the end of Bleckler’s troubles. She had to wait five hours for her son to drive down from Cody to retrieve her. And a few weeks later she received a five thousand dollar bill for the ambulance ride to Casper, which the Title 25 statute doesn’t require the county or the state to cover. Bleckler says if she hadn’t had a sympathetic boss she would have certainly lost her job. “I just didn’t know how long I would be down there.”
This scenario is not uncommon in Wyoming. The state’s psychiatric facilities are located in Cheyenne, Laramie, Evanston, Lander and Casper. Title 25 patients in rural counties are routinely subject to long drives and high fees. Many don’t get any initial psychiatric care at all. Josh Smith is the attorney for Lincoln County in Western Wyoming.
“What we are doing [in Lincoln County] now is basically we are having to find a place to hold these individuals without getting them any treatment for the first 72 hours.”
Kemmerer, the town where Smith works, is only an hour away from the Wyoming State Hospital in Evanston, which is designated to receive Title 25 patients. But the wait for an open bed there is weeks, often months, long. Smith said that has left his county with two major options. The first is the area’s primary care hospital, where a bed can cost over 1000 dollars a day and which does not provide any psychiatric care for Title 25 patients.
The second option is a bed in Kemmerer’s so-called “Justice Center” which houses among other things the County Attorney’s Office, and the jail. “We built into [the Justice Center] a room outside the secure facility,” Smith said. “Outside the jail...portion.”
This detention without psychiatric treatment is obviously bad for Title 25 patients. It’s also a burden on county budgets. Without quick care patient stays get stretched out and costly--Lincoln County budgeted 15,000 dollars for Title 25 costs last year but spent over 35,000.
However getting accurate data on individual county’s Title 25 expenses is challenging, said Wyoming County Commissioners Association Director Peter Obermueller.
“The spending for Title 25 comes from so many different parts of a county’s budget. The Title 25 budget itself really just deals with the payments to hospitals or treatment centers for the actual expense of care. It doesn’t take into account the significant legal expenses from the County Attorney’s office.”
Obermueller also said that Title 25 costs vary heavily because the number of people who suffer mental health crises in a given year is unpredictable. Because of that Obermueller said the best way to track county costs is by looking at state expenditures on Title 25, which have gone up dramatically in the last few years. “The state is only seeing [Title 25 patients] because they are continuing in treatment after the 72 hour period that the county is in charge of paying for. If state costs are going up then it stands to reason that, statewide, county costs are going up as well.”
Read the next part of our Title 25 series here.